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WELL PERMIT APPLICATION FORM SITE <br /> (6v SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> �' 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Is made in compliance with San <br /> Joaquin County Development Title, hapter 9-1115.3 and the Standards of San Joaauin County Environmental Health Department. <br /> WELL Location Cross Streei ---- ;it �u. e/ Assessors <br /> / y�Zip Parcel# <br /> PROPERTY / " � � ////'' // <br /> Owner L a Lt . Address 16Y�573�dIEkrn 14f City Zip j0 phone# Y✓d—20c/1 .�.y,., �✓ <br /> C-57 Contractor '' , nn ,// ���� Address/&) Elle.S IL City / <br /> Consultant/Sub Cntr 1�GP�/ Address C�. -��'✓T Yi✓;YZ��' Cit �iT'>4^ <br /> y , Lic# Phone yJ'-/3yf ' <br /> GIS Coordinates:X 'Y ,Township Ra ,[ Section <br /> WORK TO BE PERFORMED: F 710/ ( —;type <br /> p NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHE DESTRUCTION (choosbelow) <br /> O SOIL BORING# ER-BORE. DIAMETERGLL <br /> 0 PRESSURE GROUT <br /> 'Other GROUT SPECIFICP�TIONS t' <br /> COMMENTS: r�i,rr,' p r .c <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING *OLLOW STEM DIA.OF BOREHOLE p MULTIPLE CASINGS a MULTILE �WELL CASING DIA: �/ <br /> n EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS Sti 70 TYPE OF CASING: 0 STEEL ,,N�VC 0 OTHER: <br /> n VAPOR u MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: XAUGERS p HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING n HAND AUGER GROUT SPECIFICATIONS <br /> F OTHER: Q OTHER APPROX.BORING DEPTH 2 n BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ,`«+'; i.€P � ':�t"F- .4. rai <br /> NOTE: OFFSITE BORT GS REQUIRE ACCESS AGREEMENT ORE CROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> ,5PriSigned x ` /�7/�— Title/Company �� -"5-- <br /> Print <br /> nt Name J �� ��� �' <br /> DEPARTMENT <br /> /USS�EONLYDate <br /> ( � Date <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /d o <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area tJ <br /> Grout Inspection By Date Final Inspection 8 ate <br /> Destruction Inspection By Date - 0 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES , <br /> F,EEr 30INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> 7i7� VV 66, 12 ,7 2, SR# <br /> C-57 V WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />